04-4110. Agency Information Collection Activities Under OMB Review

AGENCY:

Veterans Health Administration, Department of Veterans Affairs.

ACTION:

Notice.

SUMMARY:

In compliance with the Paperwork Reduction Act (PRA) of 1995 (44 U.S.C. 3501-21), this notice announces that the Veterans Health Administration (VHA), Department of Veterans Affairs, has submitted the collection of information abstracted below to the Office of Management and Budget (OMB) for review and comment. The PRA submission describes the nature of the information collection and its expected cost and burden and includes the actual data collection instrument.

DATE:

Comments must be submitted on or before March 26, 2004.

FOR FURTHER INFORMATION OR A COPY OF THE SUBMISSION CONTACT:

Denise McLamb, Records Management Service (005E3), Department of Veterans Affairs, 810 Vermont Avenue, NW., Washington, DC 20420, [phone], FAX [phone] or e-mail to: [e-mail]. Please refer to “OMB Control No. 2900-0219.”

Send comments and recommendations concerning any aspect of the information collection to VA's OMB Desk Officer, OMB Human Resources and Housing Branch, New Executive Office Building, Room 10235, Washington, DC 20503 [phone]. Please refer to “OMB Control No. 2900-0219” in any correspondence.

SUPPLEMENTARY INFORMATION:

Titles:

a. Application for CHAMPVA Benefits, VA Form 10-10d.

b. CHAMPVA Claim Form, VA Form 10-7959a.

c. CHAMPVA—Other Health Insurance (OHI) Certification, VA Form 10-7959c.

d. CHAMPVA Potential Liability Claim, VA Form 10-7959d.

OMB Control Number: 2900-0219.

Type of Review: Extension of a currently approved collection.

Abstract:

a. VA Form 10-10d is used to determine eligibility of persons applying for healthcare benefits under the CHAMPVA program.

b. VA Form 10-7959a is used to accurately adjudicate and process beneficiaries claims for payment/reimbursement of related healthcare expenses.

c. VA Form 10-7959c is used to systematically obtain other health insurance information and to correctly coordinate benefits among all liable parties.

d. VA Form 10-7959d is used to solicit additional information relative to injury/illness as well as third party claim information.

An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. The Federal Register Notice with a 60-day comment period soliciting comments on this collection of information was published on November 13, 2003, at page 64429.

Affected Public: Individuals or households, Business or Other for-Profit.

Estimated Annual Burden: 394,667 hours.

a. VA Form 10-10d—3,417 hours.

b. VA Form 10-7959a—383,333 hours.

c. VA Form 10-7959c—5,000 hours.

d. VA Form 10-7959d—2,917 hours.

Estimated Average Burden Per Respondent:

a. VA Form 10-10d—10 minutes.

b. VA Form 10-7959a—10 minutes.

c. VA Form 10-7959c—10 minutes.

d. VA Form 10-7959d—7 minutes.

Frequency of Response: On occasion.

Estimated Number of Respondents: 2,375,500.

a. VA Form 10-10d—20,500.

b. VA Form 10-7959a—2,300,000.

c. VA Form 10-7959c—30,000.

d. VA Form 10-7959d—25,000.

Dated: February 12, 2004.

By direction of the Secretary.

Loise Russell,

Director, Records Management Service.